Basic Information
| Provider Information | |||||||||
| NPI: | 1831173442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | WALTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 139 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477010139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124711591 | ||||||||
| FaxNumber: | 8124716650 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 KENTUCKY AVE | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705752100 | ||||||||
| FaxNumber: | 8124716650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 38453 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00143774 | 01 | KY | RR MEDICARE | OTHER | 64084593 | 05 | KY | MEDICAID | 000000059857 | 01 | KY | ANTHEM BCBS | OTHER |